Some really exciting developments with #MatExp Whose Shoes? at the moment.

Bromley MSLC produced a ‘one year on’ report following up on their Whose Shoes? workshop at King’s College hospital using “I said, I did” as a framework to list all the fantastic outcomes that had come from pledges made on the day.

Language continues to be a big issue for women and families, but some great initiatives are now happening. Building on the Whose Shoes? workshops, Leeds and Colchester in particular are working on specific language challenges. I came up with a ‘Negativity Bingo’ and had great fun with my team at the NHS Fab Change Day #DoAthOn event launching #DumptheDaftWords.

I have been getting some exciting invitations to speak about building social movements and of course gave #MatExp a big shout out in my talk at the launch of #AHPsIntoAction, they have invited me back for a longer keynote session at their annual conference in June.

Last Friday, 3 Feb 2017, we were invited to present a #MatExp Whose Shoes? session to get some good discussions going as part of a packed event launching #PanStaffsMTP in Stafford. We concentrated specifically on continuity and perinatal mental health. This is the county-wide transformation programme to improve maternity experience in Staffordshire to implement the national ‘Better Births’ vision. This informal film gives you a flavour.

We are proud of the crowdsourced ‘Nobody’s Patient’ project and thank everyone for your fantastic contributions. We now have over 120 new Whose Shoes? scenarios and poems and the new resources will be made available shortly to all the hospitals who were existing customers. Florence Wilcock, Sam Frewin and I are finalising the supporting toolkit and collating the case studies, ahead of our ‘wrap up’ event in March. We are trying to pull together lots of ideas for positive change, with or without a workshop. I hope you are enjoying the regular Steller stories, including Florence’s monthly reports.

Wonderful to see everyone doing such amazing work, speaking all over the place, building networks, spreading the word and generally making great things happen.

Keep up the good work!

Our thanks to Sally Hogg for this blog post. Sally is a mother who works in children’s policy, research and practice, and has done extensive work on the subject of excessive crying in infants.

Sally Hogg, @salhogg

All babies cry and some babies cry a lot; between 10 and 20 per cent of babies will cry excessively during the first three months of life. As professionals, we know that this crying is normal and will pass. But for parents it is tough. Really tough.

“There were times when I resented him for screaming, and then hated myself for feeling like that, and also for not being able to make it better. I just felt a huge sense of failure.”

While most families survive a period of excessive crying relatively unscathed, it does increase the risk of a range of poor outcomes including maternal mental illness, relationship breakdown, child abuse and childhood behavioural problems.

Parents of babies who cry a lot will often try to identify a cause of this crying, and, with it, a solution. This isn’t helped by the fact that excessive crying is generally known as ‘colic’, leading to the common misconception that it is caused by stomach problems. In fact, excessive crying has been shown to be associated with digestive problems in only a small subgroup (around 5-10 per cent) of babies who cry excessively. For other babies, the causes of excessive crying might include temperament, early sensitivity, feeding problems, or a poor fit between parenting expectations and behaviours and babies’ needs. For many babies, we will never really know why they cry a lot.

Crying is one of the most common reasons that parents seek support in the postnatal period. In these situations, it can be tempting to suggest a ‘cure’ for the crying, or to reassure the parent that crying is normal. Both the academic evidence, and the experience of parents, tell us that neither response is appropriate.

It is not appropriate to simply suggest a cure for the crying – whether that be winding, infancol, changes to feeding, or actions like walking the baby in a pram or carrying him. These actions might work for some babies, but not for all. There is no ‘one size fits all’ solution to crying – all babies are different and can cry for a huge number of different reasons, requiring different responses.

It is also not appropriate simply to reassure parents that crying will pass. Even if the crying is normal and the baby fine, excessive crying is hugely difficult for parents and can damage their self-esteem, self-efficacy, mental health and wider wellbeing. So some form of response is required.

So what might an appropriate response to excessive crying be?

Based on a review of the evidence, and in particular a useful article by Ian St James Roberts I would suggest that a good response to excessive crying has six parts. These are set out below. I’ve also highlighted where we might take action in the antenatal period to prepare parents to cope with a crying baby.

Building awareness of babies’ development.

The first three months of a child’s life (sometimes called the ‘fourth trimester) is a distinct phase of babies’ development, in which they are not yet able to regulate themselves, and in which their crying has particular characteristics. Ronald Barr refers to the ‘period of purple crying’, where the acronym ‘purple’ describes different features of babies’ early crying.

Supporting all parents – both antenatally and postnatally – to understand this developmental stage, and to know that it will pass, can be really helpful. (Although there isn’t a magic transition point at three months and each stage of children’s development brings new and different challenges, so it’s important to manage parent’s expectations!)

Help parents to understand the stress that they feel and how to cope with this.

It is normal for parents to find their baby’s crying stressful, but hard to admit this. We can help parents by normalising this experience, making it acceptable to talk about how one feels when a baby cries, and helping parents to think about ways to deal with this. Evidence shows that giving parents coping strategies to deal with the stress they feel when their baby cries, together with educating them about the importance of not shaking baby, can help parents and reduce the risk of abuse to babies. The NSPCC’s Coping with Crying Programme has shown the value of sharing these messages with parents in the antenatal and postnatal period.

Provide a menu of options

There are many reasons why a baby might cry and many ways to help babies to keep calm, or to soothe them when they cry. These could be shared with parents antenatally, to help provide them with a ‘toolkit’ to draw from when their baby cries.

When a baby is crying excessively, it is useful to help parents to consider their own baby’s experiences and needs, and to identify what actions might help them. Evidence from successful interventions suggests that the most effective responses to excessive crying involve reassuring and supporting parents, and helping them to formulate hypotheses about why the baby is crying and identify and test actions to reduce their babies’ crying or to make it feel more manageable. One intervention, Possums, uses five domains – infant health, mother health, feeding, sensations and sleep – to consider the families’ needs and identify actions.

Help parents to enjoy their baby.

When a baby cries excessively, this understandably becomes the focus of parents’ attention. But the perinatal period is a formative time when parents develop beliefs about their child’s personality which can influence how they interpret and respond to the child’s behaviour and the quality of their interactions. It is therefore important to highlight a babies’ wider characteristics, and help parents to enjoy the positive interactions that they have with their baby so that they don’t develop too negative an image of their child based on their crying.

Frame crying as an experience and not a symptom.

It is helpful to address the idea that crying is a sign that there is something ‘wrong’ with the baby, either physiologically or emotionally. Helping parents to see excessive crying as a part of their baby’s experience of early life, rather than a symptom of a medical problem or a sign of poor behaviour, can help them to focus on how best to soothe their baby and cope with crying during this stage.

Be Kind.

Finally, let’s not forget that excessive crying is really hard, and parents can feel feelings of isolation, helplessness and failure. These mums and dads need a kind, compassionate response and ongoing support.

“More helpful still were the very few people at health clinics who bothered to learn my or my babies’ name, who offered to hold him for a little bit, and who were interested in how I was doing. These people were few and far between.”

Language is a huge theme for #MatExp, and one of our six Heart Values. Francesca Tucker kindly agreed to write this post for us looking at people’s inadvertent language trip ups when talking to parents of premature babies. Francesca is a part-time working Mum, who lives in the New Forest with her husband Murray, baby Harry and their three cats. Harry was born at 28 weeks, whilst his parents were on holiday in France. He’s now a happy, healthy 18 month old!

As I sit and write this now, I can do it with a smile on my face. But 18 months ago, if you’d said any of the following “Top 10” to me, my reaction would have been vastly different. Depending on how my day had gone / how many Brady’s baby Harry had decided to scare us with / how much milk I’d managed to express etc., you may have had a response of tears, anger or stony silence. Because, quite frankly, there are just some things you don’t say to the parent of a premature baby!

Speaking on behalf of “The Premature Club” which no-one wants membership to, we understand that it’s difficult to know what to say. The pure joy of the newborn news is tinged by the elephant in the room- “what if they don’t make it”? We know that as our family, friends and loved ones you are thinking of us (we do appreciate it!) and you want to say the right thing, but we’re not expecting you to – there are no magic words that will break the spell and make everything better. Just being there for us, letting us cry, shout, or just sit in silence helps. And that silence can be golden – far better than the following “Top 10 Things not to say to a Preemie Parent”! (As compiled by myself and another Prem-Mum whilst we were in neonatal, both with boobs out, trying to get our babies to practice their breastfeeding!)…..

1. You’re lucky! You got to meet your baby early!

Yep, at this time, we’re feeling really lucky-said no-one EVER! Last time I checked, there was no calendar hung in my uterus, so I’m pretty sure the baby had no concept of ETAs.

2. Your baby was just keen to meet you.

I was creating quite a nice little home in my womb which I was quite proud of- food on demand, good thermostat, nice sounds, and a lovely landlady who was providing everything. I think my baby was quite happy to stay put for a while longer, and wasn’t that eager to meet me. He/she had heard me chatting enough already, so I’m pretty sure the baby knew me already!

3. Oooh, having such a small baby must have made labour easy!

Putting aside the obvious fact that childbirth is painful, what a lot of people forget is that Prems often arrive in emergency situations. This may involve tearing, C-sections, episiotomies as well as the wider delivery tool-kit of forceps, ventouse etc. This is NOT easy! (And don’t even get me started on the emotional aspects of labour)

4. Lucky you! You’ve got less baby weight to lose!

Why is it that when someone has a baby, everyone feels it’s acceptable to start commenting on your weight?! It’s no-one else’s business that you weigh, it’s the last thing on your mind whilst listening to the endless beeping in neonatal. And chances are that with the stress of the situation, you’ll be losing weight anyway

5. Well, at least with the baby in hospital, you get a good night’s sleep!

Erm, no!! At night, most Prem parents are trying to cram in a day’s work of general life into a couple of hours (unfortunately bills still need to be paid, housework done etc.), prepare supplies that need to go to the hospital the next day, express milk through the night to keep supply up, and are generally stressing. A good night sleep is not anticipated for months!

6. With those nurses around, you’re getting far more support than most Mums.

Yes, the nurses are a fantastic support (they become your extended family!), and it’s a hard job to do, but they are by no means doing it single-handedly. They encourage the parents to get involved wherever and whenever possible. I can’t think of many parents that have a baby just to hand them over to someone else to look after – you are the parents, and you want the job! But also remember, the medical team is desperately needed- many Prems need a lot of medical support…surely no-one can begrudge a baby that?!

7. But tiny babies are so cute!

True, but would you swap your baby being dangerously small for “cute”? I thought not. And trying to find the “adorably small” premature outfits is tricky…and very expensive!

8. When will the baby be coming home?

We don’t know, and if we do, we often won’t want to say. It is upsetting thinking you’re about to take your baby home, only for your child to take a downturn and your excitement turns to disappointment and fear. Sometimes it’s easier for the parents to say nothing, rather than having to explain why the baby is remaining in hospital. And when we finally take our little family home, we may well want a day or two to take it all in-it’s a long journey to get home!

9. How are you doing?

Mmmm, a tricky one. Some days will be good, some days will be bad. With 1001 thoughts and emotions running through a Prem parents head, it’ll probably take too long for them to give an honest answer- default option is option to be “Okay, thanks. You?” A better thing to say if the offering of help for a specific thing e.g. “Would you like me to bring you a meal around, so you don’t need to cook?”

10 Will he/she be okay?

A very personal question, and again one that is completely dependent on individual circumstances. Define “okay”? The baby may have long-term health issues, but with the prospect of excellent quality of life, the outlook is overall positive. Or the baby may be going through a serious complication, where the outcome is an unknown. No-one wants to answer “No, he/she is not okay”, as it’s upsetting for all concerned. I personally think such questions are best avoided, and simply substituted by as much love and support as you can provide.

These are some of the favourite options I had for you from our early days of the neonatal journey. Now, a favourite is “Isn’t he walking yet?” – nope! But bear in mind, his peers have a 3month developmental head-start! Maybe I should do a Top 10 comments for the “Advancing Prem Baby”?!……….

But to anyone reading this, currently supporting a neonatal family – thank you. Even though the family may not show it (they are probably too overwhelmed presently), having you present in their lives is helping them more than you’ll know. And if you’re the parents of the little baby/babies lying in hospital- I welcome you to “The Premature Club”- it’s tough, and at times you may feel so wholly overwhelmed it can engulf you. But remember, you are doing a great job and making the best of your situation. I send my love and support to you.

Francesca and Harry by Rosiepics

Francesca Tucker

2016

For more “What Not To Say” and other Preemie Top Tens please visit The Smallest Things website.

This post is from Michelle Quashie, and originally appeared on her blog site Strong Since Birth. Our thanks to Michelle for agreeing for it to be reposted here.

The day had finally arrived! After contributing to #MatExp and interacting with many conversations surrounding ‘WhoseShoes’ throughout the year, I was finally going to experience the magic in real life.

Laura, the chair of our MSLC has written a fantastic post that captures the excitement of the day perfectly, you can read it here: When WhoseShoes Came To The PRUH

I was not disappointed, the day was everything I had dreamed of, but for me it was so much more.

I was asked to open the event by sharing my Maternity Experience. I have spoke at several maternity training events in the past but my audience has always been Midwives. I was aware that this was a multi discipline training event and it was to be the first time I would share my story in such detail with Obstetricians and everyone else involved in Maternity. The thought made me feel anxious but I knew how important this opportunity was.

I had planned to stay in control and not let the emotions attached to my experience be displayed in the form of tears. It was so important to me to remain composed and in control.

My heart pounded through the showing of the MatExp film, this film moves me every time. It is so powerful and very thought provoking. Sadly I can resonate with many of the situations displayed in the film. I knew I was about to be discussing some of those memories any minute with all those surrounding me.

My name was called and I made my way to the front with my heart pounding. I decided to be honest and share how I was feeling with the room.

‘Please bare with me, I am feeling very nervous. I’m sure once I start talking I will warm up and I will be fine!’

Automatically I felt more relaxed and felt more able to share my story without the anxiety overruling my thoughts.

It’s amazing how every time I share my experience it comes out slightly different, or I find myself saying things that I hadn’t thought of before? I had missed a couple of important bits out but neither the less I was very happy with the way I had presented and gauging by the feeling of emotion in the room I had touched the hearts of nearly everyone around me. For the first time I was able to keep my tears to myself even though I had noted that tears were shed by many in response. The room fell silent but the atmosphere spoke volumes.

I wasn’t aware of the tweets that were being circulated on social media but looking at them them later along with the emails I had received It confirmed that my talk was a positive part of the day.

“Also a massive well done to Michelle for her heartfelt and emotional story, I could see it touched many people as there were certainly a few tears in the room. That took huge courage to stand there in front of so many people and share such a personal experience and to tell it so well. Huge WELL DONE Michelle.”

We began to play the the game and interesting discussions were had in response to the thought provoking questions that are key to the WhoseShoes success.

Some of the discussions that stick in my mind were:

A woman wanted a home birth but her husband wasn’t convinced. We had discussed that there wasn’t enough support or information given during antenatal care to ensure that the couple felt safe,supported and empowered to fulfil the woman’s birth choice.

Consultant Obstetricians are normally addressed by other members of their team using their title i.e., Sir, Mr, Mrs or Miss as a mark of respect. I may be wrong but it feels hierarchical, unlike the power slogan and barrier breaker behind WhoseShoes and #MatExp ‘No Hierarchy, just ordinary people’.

It was also discussed that consultants were on site until 9 pm, after that they are on call for emergency situations only. Now I understand why during my appointment to discuss my VBAC, the registrar said ‘ I mean, we don’t know when you will go into labour or who will be on duty should you rupture’. I now understand that my birth choices were influenced by staffing levels at the hospital.

Other key themes were Empathy, Language, supporting and facilitating informed decision making and just how important it was for everyone to be cared for individually based on their individual situation and needs.

Midwives are able to have time to build a relationship with women whereas doctors are often called for the emergency situation and do their best to resolve the medical issue as it arises. This can sometimes make it hard for them to be able to connect with the woman that they are caring for and are not always able to fully appreciate the long lasting effects the experience can have on a woman.

The day was coming to an end and Anna gave us fabulous evaluation of our morning using the comments that came from the discussion at each table. It was fabulous to visualise the discussion using the graphic that Anna had been working on through out the morning.

We each made an individual pledges. Here is my pledge:

“To provide a platform for women to share their Maternity experience. I would like to ensure that women’s voices are heard as part of training and development.”

I am currently planning a conference called ‘Women’s Voices’. More details will be available soon.

As the morning came to an end and people were leaving someone tapped me on my shoulder. I turned round and my tummy flipped. The face before me took me straight to a place of feeling vulnerable, feeling panicky.

‘Michelle it was me wasn’t it?’

Stood before me was the registrar that I had my consultation for my vba2c with. Unbeknown to my self and the organisers we had shared the morning. I had shared an experience that changed my life but had also been a time that left me feeling scared, vulnerable, isolated and questioning my mental health. The person that was responsible for those feelings was standing here in front of me, for a moment the feelings came flooding back, I battled to keep them contained.

She apologised for the way she had cared for me. She admitted that she had been wrong and has since ensured that she was fully aware of her professional guidance. She was now fully supportive of women’s choice regarding their birth and ensured me that since having to write a statement in response to my complaint, she is fully aware of the impact of the care she provides a woman.

She actually thanked me for highlighting the error of her ways promising me it had changed her attitudes. I could see that she was overwhelmed with emotion and had spoke to me honestly. She asked if she could hug me and we both held each other for comfort.

I told her that I admired her for taking the time to come a talk to me and for apologising. I also explained that I was aware that she was not entirely to blame for the care I had received and I now understood that her response to me wanting a vaginal birth after two caesareans was due to the cultural belief of the trust she worked in.

It was clear that my birth wishes would not be supported and neither would anyone wanting to support me at that time. I know this because many attempts were made to provide me with the support I needed and no one stepped out of their comfort zone to provide me with the support I needed with regards me birth choices. As a result I had no choice but to transfer my care.

She empathised and promised me that as a result of my experience things were changing.

We said our goodbyes and I was trying very hard to contain my emotion that the meeting had evoked.

A consultant midwife that has walked by my side through this maternity experience and others and who has been a pillar of support to me came to see me. ‘Are you OK Michelle?’

The flood gates open and I broke down. I couldn’t talk at that moment. I was just overwhelmed with emotion. I couldn’t make sense of it at the time but now I think I can.

That meeting with the registrar brought some closure. I admire her ability to acknowledge the error of her ways.

The meeting took me back and reminded me of the scared women I once was sitting in her office, trying to persuade her that I could give birth, pleading with them to allow me. Feeling so horrible when it was highlighted that I had never given birth and they wasn’t sure if I could. I was subjected to a number of negative comments that effected my mental well being and left me questioning my sanity. Comments that left my family feeling unable to support my decisions in fear of my safety. it was a meeting that left me feeling isolated.

Here I sat after coming full circle with the same women but this time I was a different woman. I am a now a woman who has had the most amazing journey and have achieved some incredible things;

I gave birth, not only did I give birth but I bloody rocked that labour ward!

I came back and I told the story, I sang it from the rooftops!

I learnt to believe in me and my abilities.

I joined their MSLC and contributed to so many fantastic improvements within the Maternity service.

I have spoke at training events within maternity with an aim to improve maternity care for women.

I have written and had my views published here and in The Practising Midwife .

I have contributed to #MatExp campaign and connected with some fantastic people as a result.

I have met, received support and been inspired by many fantastic people. too many to mention.

The realisation that my shoes have climbed a mountain has happened!

I received the following email from a Consultant Obstetrician following the Whose Shoes event. It confirmed that this journey has been worth every little step:

“Dear Michelle,

I just wanted to reiterate how touched I was by your story and how impressed I was by the way you delivered it. You will be responsible for improving the practise of every obstetrician in that room today which in the end will improve the care of tens of thousands of women.

I would like to take this opportunity to share my views on why I feel so strongly about the role of the Maternity Services in Perinatal Mental Health (PMH).

Perinatal Mental Health (PMH) has two important components in its terminology: ‘Perinatal’ (period during pregnancy, delivery and post delivery) and ‘Mental Health’. Therefore the care of mums in the Maternity Services during this vital period is of utmost importance in PMH: it should be a no-brainer.

But sadly, PMH is the only one area of Maternal Health where I do not see a strong voice of the Maternity Services in the national campaign.

This has remained ‘Cinderella’ within Maternity Units in spite of the glaring facts:

PMH is still one of the leading causes of maternal death in the UK.

This is one of the most prevalent conditions mums suffer from during their pregnancy and postpartum period (at least 10% of mums suffering from this).

I strongly believe that without robust ‘perinatal’ care, women would continue to suffer and die from PMH illnesses, no matter how much we spend to expand specialist Mother and Baby Units (MBUs).

Therefore this is the time when we must recognise this important area and raise awareness.

I am trying to address this issue through my campaign on social media and as the Royal College of Obstetrician and Gynaecologist’s (RCOG) Representative to the Maternal Mental Health Alliance (MMHA).

What do I mean by PMH ‘within’ Maternity Services?

Suffering and deaths from PMH illnesses are often preventable if appropriate measures are taken during pregnancy and in the immediate postpartum period.

A prevalent health condition like PMH must be managed with the same readiness as managing other medical conditions in pregnancy such as diabetes, high blood pressure (pre-eclampsia) or heart disease.

The only way to ensure that the women with PMH are appropriately cared for according to the NICE guideline (2014) is to have:

A dedicated PMH team within every Maternity Service:

A Consultant Obstetrician, Specialist Midwife, a Perinatal Psychiatrist, a Specialist Psychiatry Nurse and a Paediatrician should jointly lead this service locally. The service should be easily accessible to the mums.

A dedicated Obstetric-Psychiatry Antenatal clinic

Communication with Community Team:

This Maternity Service should have clear links with GP, Health Visitor (HV), community MH Team, Liaison Psychiatry services, Mental Health Crisis Team, Children and Young People services, Peer Support groups and other charitable organisations.

Robust Care Pathway:

There should be a clear pathway for risk assessment (at the booking visit and at every consultation), early identification and treatment. There also should be provision of a multi-professional team meeting on a regular basis.

Dedicated specialist service and support:

For conditions such as PTSD / birth trauma, fear of pregnancy and child birth (‘tocophobia’), bereavement and support for mums and dads whose babies are admitted to NICU.

Pre-pregnancy advice service:

It is important to have specialist advice and support for women (with PMH illness/ traumatic experience in previous pregnancy) who are considering pregnancy.

Patient involvement : ‘Patients first and foremost’

PMH is an area where patients’ opinion must be considered in developing local care pathways. Services must be evaluated on a regular basis based on patient experience.

I firmly believe that all the health conditions should be treated in the same way with professional expertise and kindness and without any prejudice. I am not sure why we still classify health conditions into ‘physical’ and ‘mental’ when there is often an overlap.

Psychological care in pregnancy, delivery and beyond…

It is unfortunate that psychological care has remained a very neglected part within Maternity Services. The reason given for this is ‘the staff are too busy’.

However pregnancy is probably a period of life where psychological support from the HCPs is needed the most.

It is especially important when mums could potentially have severe stress during pregnancy and the postpartum period due to the following factors:

Many believe that PMH is a term equivalent to the care of Postnatal Depression (PND) and PP.

PMH includes specialised care for women (during pregnancy and one year after the childbirth) with any mental health condition (such as anxiety, depression, bipolar illness, schizophrenia, OCD, eating disorder, and personality disorders).

PMH must include bereavement care (miscarriage, still birth and neonatal death), traumatic birth experience/PTSD, support services for mums and dads whose babies are admitted to NICU and tocophobia (fear of pregnancy and childbirth).

Another important component should be the psychological care of mums and dads throughout the journey of pregnancy, delivery and postpartum period.

PMH, in my view, must be recognised as a separate subspecialty in the training of Obstetricians and Midwives.

Why is identification in pregnancy and immediate postpartum period so important?

Effects of psychological stress in pregnancy:

There are now plenty of research results, which indicate the long-term impact of stress during pregnancy on the brain development of the baby while it is in mum’s womb. Prof Vivette Glover, an eminent Professor of Perinatal Psychology from Imperial College London, explains this: http://www.beginbeforebirth.org/for-schools/films#womb

Therefore timely intervention and adequate support during pregnancy can prevent long-term effects on the child.

Care Planning to prevent serious illness:

All pregnant women with risk factors to develop worsening mental health conditions should have a plan of care during delivery and postpartum period.

Confidential Enquiries into Maternal Deaths have repeatedly pointed out that in the majority of cases of deaths from suicide, there is a lack of care planning during pregnancy.

This is only possible through appropriate care within the Maternity Services and multiagency communication.

Enjoying the journey of pregnancy:

Experience of pregnancy and birth creates a lasting memory for the mums and dads for the years to come. Therefore this should be an enjoyable experience for the woman and her family to cherish in happiness in the future.

As HCPs our role is to ensure we support and empower women to make informed choices for the safety of her and the baby and most important of all a very positive birth experience.

Helping mums to make informed decision regarding medications:

Mums should get proper advice regarding the use of medication in pregnancy and after delivery.

Pregnancy is a short window but an excellent opportunity to address health conditions.

Bonding and attachment:

PMH conditions can adversely affect the bonding with the baby and the mum.

‘A stitch in time saves nine’: Prevention of serious PMH illnesses is only possible through good care in Maternity Services.

Having discussed the importance of the role of Maternity Services in PMH, now let us find out what is happening in the Maternity Units……

A journey of revelations…

I contacted many Maternity Units across the country to find out the provision of PMH services within their Units. What I found was extraordinary.

I raised this issue with the Maternity Review Team, during my meeting in September (2015).

Although there are examples of good service, the overall structure within the Maternity Units is very poor:

Often there is no dedicated Lead Obstetrician and/or Specialist PMH midwife

Many Units do not have formal debriefing services (for traumatic birth experience), specialist bereavement midwives and support system for parents with babies admitted to NICU.

There are hardly any dedicated services for women with fear of childbirth.

Delving deep into the challenges….

To have a better understanding of the need, I embarked on a journey to meet professionals from all the relevant Royal Colleges (RCOG, RCM, RCPsych, RCGP), Health Visitor organisations, Maternal Mental Health Alliance (MMHA), MPs and All Party Parliamentary Group (APPG), NHS England, CCGs and other national Campaign Groups.

It was revealed that overall there is very little understanding of the vital role of the Maternity Services in PMH.

Thankfully RCM is campaigning for a Specialist Midwife in every Maternity Unit.

But the main barriers are the following:

Lack of Mapping of the existing services in PMH within Maternity Units (such as the MMHA map of the available Perinatal Psychiatry services).

Lack of a national standard of the service provision within Maternity Units (according to the number of deliveries and complexity of cases).

Poor collaborative work among HCPs: as often the Maternity Electronic record system is not accessible to other HCPs and vice versa.

Lack of standard Training programme for the Obstetricians and the Midwives.

Lack of adequate focus on PMH illnesses in Antenatal Education.

I have concerns that unless these issues are resolved appropriately, we cannot provide the best quality of care for women with PMH illnesses.

With the best of my abilities, I am currently working closely with other national organisations to address these areas.

Maternity HCPs:Please, please do something and don’t wait for things to happen….

It is true that funding is necessary to set up specialised PMH services and Mother and Baby Units (MBU). However Maternity Units should not wait for the approval of their business cases.

In my humble opinion, funding is not everything. Our professional values are the most important factors in patient care:

Kindness:

Simple measures such as a smile, empathy and a willingness to listen to the concerns of the mums and dads could make a huge difference in patient experience.

Communication:

Take every opportunity to explain the situation and ensure that appropriate wording is used during communication.

Continuity of care:

Try to ensure continuity whenever possible or communicate adequately with the rest of your team.

Local Alliance:

Please try to develop Local Alliances with Community Midwives, Health Visitors, GPs, all available community mental health services, Peer Support groups and children’s services.

This could significantly improve communication among the multi-agency teams in caring for mums with PMH illnesses.

Listen to concerns:

Please create opportunities to listen to the concerns of the user group. This may be in the form of promoting your local Maternity Service Liaison Committee (MSLC) or Patient Panels.

If possible, please read the real life stories of the Lived Experiences on the Internet: it would help you to think ‘outside the box’, have a better insight into the PMH illnesses and give you inspiration.

Raise awareness:

Arrange patient engagement events, Road shows or Community Events with local CCGs.

There has been much discussion recently about safety within maternity services including a discussion on #MatExp Facebook group. A particular issue that bothers me is the idea that safety and experience might be two separate and mutually exclusive issues and it is this thought that drives me to write today.

Safety is paramount. The purpose of maternity services is to provide safe care through the journey of pregnancy and early newborn life. Every appointment in the NICE pathway is designed to screen for potential problems and ensure they are managed effectively. Every healthcare worker know this is the aim. The 20 week ‘anomaly’ scan might be considered the time to discover the sex of your baby if you wish and to get some photos but the medical purpose is to ensure the baby is growing well, with no abnormalities and to check where the placenta is localised to exclude placenta praevia (low lying placenta) which can cause life threatening bleeding.

But there is more to pregnancy and becoming a parent than safety isn’t there? I am currently reading Atul Gawande ‘Being Mortal’ where he eloquently demonstrates that keeping elderly people ‘safe’ is not enough, there is more to life and living than safety alone. He describes a number of times when giving elderly people purpose such as a plant or animal to look after or more freedom to live the way they wish despite disability it makes a significant difference to their wellbeing. Sometimes this path may deemed ‘less safe’ but for that individual may make all the difference. This comes back to choice. Safety & choice can be tricky ones to combine successfully.

This does not mean I am belittling safety. As a consultant obstetrician it falls to me to talk to couples when the worst has happened and their baby has died. I also care for women who have had unexpectedly life threatening complications. I know I am with them during probably some of the darkest hours they will ever experience. I cannot pretend to understand how they feel but I do know I have been part of those intimate moments of grief and with some families that has followed through into supporting them sometimes for years. As a hospital we have a robust process of incident reporting and the feedback from a Serious Incident investigation (SI) again will sometimes fall to me. In some cases there is nothing that we think could have been done differently in some cases I have to sit and tell an anguished couple that we have failed them and that maybe things could have been different. It is a devastating thing to do, there is absolutely nothing that can be said that will make the situation better. It feels as if you have personally have taken their existing despair and dragged them into an even more unthinkable place and the only thing you can say is ‘sorry’ which feel hopelessly inadequate and trite for such a situation.

So if I could guarantee safety I would in a flash but it is not that simple. Maternity care is delivered by people and unfortunately to err is human. We cannot design a system free of risk because however hard we try the variable of human error gets in the way. We can introduce systems that help minimise the impact of these errors but we can’t eliminate them. My favourite analogy for risk management is James Reason’s model of Swiss cheese. The event only happens when the holes in the ‘cheese’ line up the rest of the time the barriers put in place prevent the error. An example in maternity care might be the introduction of what we call ‘fresh eyes’. A midwife looking after a woman on electronic fetal heart monitoring might misinterpret this or not see the subtle changes over time if she has it in front of her constantly. ‘Fresh eyes’ means another midwife or obstetrician comes and looks at the trace on an hourly basis. This means if unusually the first midwife has made an error there is a system that means it is more likely to be corrected.

The concept of a ‘No Blame’ culture is another example designed to minimise human error. The idea that if one sees or makes an error one should report it without fear so that learning can be gained from it. It may be the learning will be the need for some individual training but equally it might be something totally different. If staff are fearful of consequences then under reporting might be the result and safety gaps may not be identified. Encouraging openness about mistakes and errors is vital but difficult. In maternity it isn’t as if we can just operate our way out of this problem .We know the huge rise in Caesareans sections in the last 30 years has not improved the outcomes for babies but has instead cause maternal health problems. So in maternity as other medical specialties we have to constantly refresh and re-invent what we are doing to try and improve safety. As obstetricians we tread a difficult path trying constantly to call correctly just the right amount of intervention at just the right time.

So where does experience fit in I hear you ask? There is abundant published evidence of positive association of patient experience with clinical safety and effectiveness, in other words if your patients (or I prefer users) are having positive experiences then you are running a safer service. It’s hardly surprising if we communicate and explain things to women and their families that we will be more likely to communicate effectively to other members of the multidisciplinary team. If we are open and honest then woman can challenge assumptions and make sure we haven’t missed something critical, a woman knows her own history inside out whereas we might omit a key point. To me one of the most shocking things that was said at our ‘Whose shoes’ #MatExp workshop last year was that women can feel intimidated and unable to ask questions. Trust and understanding between health professionals and those we care for are vital. We cannot possibly hope to improve safety in isolation, experience has to improve too.

There are two specific elements of #MatExp of which I think epitomise the safety -experience overlap. The first is an on-going ever growing constructive conversation between women, families, obstetricians, midwives, health visitors, paediatricians, families and anyone involved in maternity services. Only by tackling the difficult conversations without hierarchy in an equal and respectful way can we improve maternity care. Listening and talking to one another is critical not only as we work with women but in dissolving those barriers and difficulties that sometime exist between different professionals. Flattening of hierarchy, team work and the ability of anyone to challenge is a well-recognised component of a safety culture. We are doing this both locally using the workshops and board game and more broadly via social media and the website.

The second element of #MatExp is that personal sense of responsibility to take action. Own what you are doing and why you are doing it. ‘Wrong is wrong even if everyone is doing it’ that doesn’t mean leave it to someone else. It means that health professionals and women can take action and influence maternity experience up and down the country and through that impact on and improve the safety of maternity care. So in final answer to my question I do not think it is a choice safety or experience I believe the two are fundamentally intertwined. So what will you do to improve #MatExp?

A while ago on a Facebook birth forum I saw the phrase “you won’t grow a baby too big for you to birth”. It was a familiar phrase as it was something I would hear regularly on the homebirth e-group I was a member of back in 2010 when I was pregnant with my first. Back then I accepted it as the truth, but having been involved in #MatExp for nearly a year I have learned that few things to do with birth are that simple. So I asked the question on the #MatExp Facebook group:

What followed was a fascinating discussion. Information was shared from lots of different quarters, and evidence was linked to. Experienced birth practitioners shared their views and a few themes started to appear. All along I knew I was intending to write up the discussion as a blog post so I was trying to keep up with the information and understand what was being said. As I opened up links to studies, trials, journal articles and so on my heart sank as I am not the best at analysing that kind of thing and it seemed at first glance that the evidence shared was somewhat contradictory. So I was concerned that I would end up inadvertently talking rubbish in this post.

And then I realised that this is exactly the problem. I am a woman of childbearing age who has had an education to degree level, English is my first language and I discuss birth and maternity pretty much every day. When we talk about informed choice we mean sharing all of the evidence plus the benefit of experience with pregnant women and their families, so that they can go through it and make their own decisions. Yet if I were writing this today as a woman who had been told she was likely to have a “big” baby I would be confused. And a little scared.

So it’s a good job I didn’t know any of this when I confidently went on to give birth to my 8lbs 13oz son on all fours on our bathroom floor.

Let’s pretend for a moment that I am in my third trimester and have been told by my midwife that she suspects baby is going to be a big ‘un. Probably a bouncing 9lbs tot. Before I go down the route of “doing” anything about that, or amending my birth plans, I have asked the #MatExp group for some information. What have I discovered?

Well, firstly we need to know a little bit more about this fictitious me. Do I have gestational diabetes? Am I classed as overweight? No? Okay then, we can stick with our issue being only the predicted size of my baby and keep questions of GD and BMI for another day if we may. Similarly, we will assume that I am physically able. So why are people sucking their teeth and looking concerned that baby might be of a generous size?

This is where we come to shoulder dystocia. “Shoulder dystocia is when the baby’s head has been born but one of the shoulders becomes stuck behind the mother’s pubic bone, delaying the birth of the baby’s body. If this happens, extra help is usually needed to release the baby’s shoulder. In the majority of cases, the baby will be born promptly and safely.” (From https://www.rcog.org.uk/en/patients/patient-leaflets/shoulder-dystocia/)

In the majority of cases, the baby will be born promptly and safely? So what’s all the fuss about then? Well let’s look at this passage from the abstract of this article:

“Shoulder dystocia remains an unpredictable obstetric emergency, striking fear in the hearts of obstetricians both novice and experienced. While outcomes that lead to permanent injury are rare, almost all obstetricians with enough years of practice have participated in a birth with a severe shoulder dystocia and are at least aware of cases that have resulted in significant neurologic injury or even neonatal death. This is despite many years of research trying to understand the risk factors associated with it, all in an attempt primarily to characterize when the risk is high enough to avoid vaginal delivery altogether and prevent a shoulder dystocia, whose attendant morbidities are estimated to be at a rate as high as 16–48%. The study of shoulder dystocia remains challenging due to its generally retrospective nature, as well as dependence on proper identification and documentation. As a result, the prediction of shoulder dystocia remains elusive, and the cost of trying to prevent one by performing a cesarean delivery remains high. While ultimately it is the injury that is the key concern, rather than the shoulder dystocia itself, it is in the presence of an identified shoulder dystocia that occurrence of injury is most common.

The majority of shoulder dystocia cases occur without major risk factors. Moreover, even the best antenatal predictors have a low positive predictive value. Shoulder dystocia therefore cannot be reliably predicted, and the only preventative measure is cesarean delivery.”

Ah, okay. So whilst MOST cases are not a problem, when there is a problem it can be very serious. And most experienced obstetricians will have seen this happen, inevitably influencing their perception of the risks involved. The teeth sucking is a bit more understandable now.

Apparently if I have a small pelvis it is more likely that baby will get his shoulders stuck. How do you know if you have a small pelvis? Small compared to what or whom? I have no idea but it appears to be a consideration. One birth professional observed that “to me that ‘big’ is subjective in a lot of cases. A 7lb baby could be big to one woman whereas a 10lb baby could be average to another. There needs to be far more than just the picture provided by a (often inaccurate) scan. Woman’s own birthweight for example, her stature etc.” It was mentioned that pelvimetry used to be widely used but has been abandoned in favour of scans, due to a Cochrane review that found these measurements did more harm than good.

There is a higher likelihood of shoulder dystocia in bigger babies, that much is undisputed. Yet the language used when discussing this risk makes a big difference to how a pregnant woman might view the risk. Contrasted with the passage above is this from Evidence-Based Birth:

I suspect as with so many birth choices, women are likely to get the reassuring language from midwives who have confidently dealt with many instances of stuck shoulders, and more wary language from obstetricians who have seen first hand what can go tragically wrong.

So in summary shoulder dystocia is more likely in bigger babies but on the whole it can’t be predicted and can usually be dealt with. It turns out that there are arbitrary cut offs for recommending Caesarean to prevent SD – 5kg in a non-diabetic woman. That means nothing to me but a quick Google tells me that is an 11lbs baby. My hypothetical nine pounder doesn’t warrant an automatic recommendation for a c-section then. So far so good.

But what position is my baby in? This is an important factor. I would argue that all pregnant women should be aware of foetal positioning and how to optimise it, but in this case it is particularly important as a malpositioned big baby could cause trouble. Let’s assume though that I have been on spinningbabies.com, haven’t been reclining on the sofa, have been doing headstands for nine months or whatever it is that is recommended. Baby is now head down and engaged and we’re ready for the off.

At this point it’s good to know that there is no evidence to suggest that it hurts more to give birth to a big baby. I cannot comment as my firstborn is the only child I have birthed vaginally so have nothing to compare it to. But the midwives on the group have been reassuring that being predicted a “big” baby does not mean increased pain in labour. Good stuff.

What I haven’t done (but what might have been recommended to me) – I have not had a growth scan. It appears that growth scans should be used to identify small babies (a discussion for another day no doubt) but not big ones. One group member commented “Ultrasound scans become increasingly unreliable the further along in pregnancy they are performed. Weight is an ESTIMATION can be up to 25% out either way. They base it on the abdominal circumference, head circumference & femur length – try doing it with yourself & see how accurate it is!”

A birth professional went on to say “Growth scans are pretty hopeless in the third trimester – the only thing that is useful is a regular plotting of growth to try to identify a sudden growth spurt that could indicate a problem. A one off growth scan late on in pregnancy basically just leads to unhelpful fears on all sides.”

Which begs the question, how do we identify the potential 11lbs babies who “require” a c-section birth?

So I haven’t allowed anyone to worry me further with a most likely inaccurate scan reading. We think baby is going to be big but not so big that I am going to be encouraged to have an elective c-section, so I’m happy to go ahead with my vaginal birth.

This is where we come to the issue that dominated the discussion. The position that women labour in can make a HUGE difference to the outcome when they are birthing a large baby. Labouring on their back is most likely to be unhelpful. Labouring on all fours is most likely to enable them to birth without intervention. Certainly my experience – I could not bear to be in any position other than kneeling up for my entire labour, simply could not bear it. Lying down was absolutely out of the question.

One group member had a wealth of information to contribute and commented “There’s plenty of evidence to support programs like birth ball use, not just gentle bouncing but using as a structured exercise plus also designing maternity units/rooms to encourage movement and position changes and upright movement.”

A midwife explained “I worked with a lovely obstetrician a few years ago (I have worked with many wonderful obstetricians). She was leading the skills and drills component for obstetric emergencies of the yearly mandatory training. We were practicing what to do in the case of a shoulder dystocia with a mannequin. She looked at me and said, of course we all know that if we do this (turning the model over in to what would be an all fours position) we wouldn’t have to be doing this at all.”

And one of our obstetricians added “in terms of labour progression, size is not nearly so important as baby’s positioning and flexion.”

The impact of pain relief was also mentioned: “Of course this is impacted by maternal position too, often compounded by an epidural that softens the pelvic floor muscles reducing the baby’s ability to rotate on the pelvic floor.”

Let’s recap. My midwife has said that it is her experienced opinion that I am going to have a big baby. I have declined a growth scan but we are both confident that baby won’t be topping 11lbs. So we’re going for a vaginal birth, and have done everything we can to ensure baby is in a good position. I am then being encouraged to be active in labour, labour on all fours and so on. There is no reason to believe that I will experience more pain due to baby’s size. There is an elevated risk of shoulder dystocia but my birth team are trained to deal with that. Hmm, okay, on reflection I would make the same choice I made back in 2011 when I hadn’t had this conversation. Home waterbirth with experienced midwives please! Especially, for me as an individual, “big” babies are normal – I was 9lbs 11oz at birth myself.

Does the above sound like the experience most women have when a big baby is predicted? Let’s ask some real life women shall we? Here I am indebted to the fabulous women on my other Facebook group who have shared their stories with me.

“I was told I would have a big baby. The midwife measured me way off the chart at 36 or 38 weeks can’t remember which. Went for growth scan. Again measured me pretty big. Appointment with consultant, he measured me big. Straight aways did a growth scan. I was then booked in for an induction the following week. Was in from the 25th and had him on 29th (due on 5th July) he was only 8lb 2oz.” What was the reason for the induction? “Not sure. They said as it was my first I probably would go over so as he was measuring big now it could be more of an issue in 3 or 4 weeks.”

“My 1st baby was 9lb 14oz and got stuck with shoulder dystocia and born with the ventouse.” And what positions were you labouring in with baby no. 1? Were you on all fours at all? “No! I believe position/ventouse were what caused her to be stuck! I was dehydrated so they made me stay in the bed on my back to be monitored!”

“I was told my little boy was a big baby and I had to have a growth scan. I was then induced a week early due to his size. He weighed 8lb 15oz and I had a 4th degree tear and had to be rushed to theatre.”What did they say were the risks with him being big? Did they explain why they wanted to induce you? “The explanation for me being induced was if I was left and went over I would have had a tough time, but looking back now I wish I had opted out of being induced as I blame that for the complications.”

“I was measuring big for dates at my midwife appointments from about 24 weeks. I was eventually sent for a scan to rule out polyhydraminos at about 32 weeks. The scan results were ok and showed that my baby’s measurements were on the 95th centile. I was then changed to higher risk consultant led care. They told me it was due to the baby’s size and the increased need for intervention during delivery, e.g. forceps, etc. My baby was predicted to be 9lb 9oz maximum and she was actually 10lb 6oz. I was in slow labour for 6 days. I had to have an oxytocin drip to get me from 7cm but I couldn’t get passed 8cm as her big shoulders meant her head wouldn’t press down on my cervix! As a result of being on the drip, I wasn’t able to get in different positions in labour and was mainly confined to the bed. I then had an emergency c-section due to failure to progress.” How did all the talk of having a “big” baby affect how confident you felt in being able to give birth? “To be honest, it did affect how confident I felt giving birth. I was then very nervous at the prospect of tearing or that I’d have difficulties during the birth and would need forceps, etc. I was very worried that something would go wrong. To be honest, I felt very relieved when the consultant said I needed a c-section.”

I commented that I wondered whether that was the reason the mum above struggled to dilate. Rather than failure to progress perhaps her caregivers should be have been labelled with “failure to encourage”.

There was one rather different story, although the mum in question was surprised by how her consultant’s advice varied from what others were experiencing: “Was told based on my daughter being 10lb that my little boy would be big. The midwife referred me to a consultant as my fundal height was bigger than even my little girl was! Tested me for GD which I didn’t have. Consultant said he was going to do absolutely nothing about it which varied massively from my peers at nearby hospitals who were being induced early. He said inducing a large baby is dangerous as they’re more likely to get stuck and if I got my little girl out this one would be fine! Bit worried but I trusted him.”

And what of those women who had not been told to expect a big baby?

“I had a 9lb 4oz baby but wasn’t expecting him to be ‘big’ I had a tiny bump and was told he was only going to be about 7lb. I had him naturally with no complications at all. A few stitches externally but that was all.”

“My 2nd baby was 9lbs 6oz and no one knew he would be that big as my first was 7lb 11oz. Labour was very quick and vaginally delivered with 1 stitch.”

“If 9lb2oz is classed as a big baby then mine was! He was 13 days over so probably wouldn’t have been so big if I’d gone on time. Nobody told me he was going to be big at any of the extra monitoring appts I had the week before he arrived all on his own, no help, drugs or hospital. I did tear slightly but midwife was happy for me not to go to hospital if I didn’t want to.”

“I wasn’t told I was going to have a big baby, I was tested for diabetes at one point because my bump had grown quite quickly but I didn’t have it. My little boy weighed 9lb 15oz, I was in labour for 6 and a half hours and didn’t have any complications. I had a few stitches afterwards but nothing major.”

What can we say in conclusion? When a baby is identified as potentially being “big” are all families given the information that we have discussed here? Do all birth professionals agree with the general thrust of this post or have some important points been missed or misrepresented? And if I have got it all wrong what does that say for the idea of “informed choice”? Because this is my best understanding of the issues following a detailed discussion with experienced birth professionals. There are plenty of other birth stories from the mums on my group which make it clear that women are routinely being encouraged down the route of induction without fully understanding why, only that baby is going to be “big” and that is some kind of a problem. And so many of these stories end in instrumental deliveries, emergency c-sections and, at worst, traumatic births. Would it not be preferable for women to have the issues fully explained to them and to be encouraged to have an active birth where, in all likelihood, they will be capable of giving birth to their child?

I am just glad that my “big” baby is here, safe and well, and now in his second week at primary school. Decisions always seem simple in hindsight.

Some of the links that were shared as part of the discussion not already linked to above:

On Wednesday I attended the NHS Expo in Manchester as part of the #MatExp team. During our session a few of us stood up to explain what the campaign means to us. My personal bit went as follows:

It is this combination and collaboration of so many different people, from across the maternity world, that makes #MatExp so exciting to me. So many conversations are being had within established communities – midwifery conferences, positive birth groups, obstetric organisations, mother & baby groups, but with this campaign these communities are coming together. And as I say, we are not shying away from the difficult conversations.

With this in mind, I decided to broach some subjects on the #MatExp Facebook group that could be considered “difficult”. I was unsure with which to start, and then this tweet from Emma Sasaru launched a conversation this morning and I just went with it.

What has followed today has been a thought-provoking discussion that has challenged many of my assumptions and made me change my mind more than once. As with the best discussions, I am still not sure what my conclusions are but it has given me new perspectives. The original question posed was:

The blog posts I refer to are Sheryl’s birth story on my own blog, and Southwark Belle’s piece entitled “Normal Not Normal“. I then went on to observe that when I hear the phrase “normal” birth I am imagining that people simply mean “vaginal” birth. Is it as simple as that?

Well no, no it isn’t. It quickly became apparent that there are a couple of definitions of “normal birth” available. One group member explained that “Interestingly, one of the first definitions of normal birth came in 1997 from AIMS, the radical women’s organisation, who defined it as ‘a physiological birth where the baby is delivered vaginally following a labour which has not been altered by technological interventions’. So this was a movement that was led from a women’s organisation to counter the over-medicalisation of birth.”

And from this 2010 publication:

And from this in 2007:

It seemed that the word “normal” had specific meanings for groups researching and monitoring maternity outcomes, and that this was a discussion that had been had many a time. Indeed, Sheena tweeted this morning

So why is it such an important and emotive discussion? Well because we have learned time and again in #MatExp LANGUAGE MATTERS. Words have huge power and different people understand things in different ways, depending on their experience, perspective and knowledge of the subject in hand. Declaring that some types of birth are “normal” begs the question what are the other types of birth then? And if the opposite of “normal” is “abnormal” are we comfortable telling women that is how we define their experiences?

It was clear that for many women the term “normal” is perceived as carrying a value judgement. It is not simply a medical or scientific definition, it is a statement about them and their experience that allows for feelings of failure and inadequacy (as with so much to do with the massively emotive subjects of maternity care). Comments included:

“where I work in a different area of healthcare, it’s understood that everybody’s normal is different, my normal vary vastly from your normal, but there is a range of normal we would expect that to be in. Having babies is different imo because you are doing something you don’t do very often so it’s difficult to define your ‘normal’ and where that might fall on the large scale of normal within birth. It can lead to people feeling inadequate.”

“the feeling of doing it wrong, not experiencing a normal birth can put people off a second time. A friend of mine is terrified because last time it all “went wrong” and she’s adamant that she won’t get pregnant again unless she can have an elective section because her body can’t do it properly.”

“Who has set the definition for normal. How do we know what normal is? How did women birth 20, 50, 100, 1000, 5000 years ago? What about culture? What is normal here may not be normal in other lands, races etc. Normal is an awful word because it gives the idea everything else is abnormal so therefore not right or not as good or missing the mark. But that is harmful label to add to a birth experience for many many reasons.”

“By terms such as ‘normal’ we make women believe that if they don’t attain that they have not done something they should. That in turn may make them feel they have ‘failed’.”

Emma kindly provided a dictionary definition of the term and observed that “its definition doesn’t relate to birth in any way”.

And of course there is also the fact that our definitions here do not match up. The definitions of “normal” birth explained above are not currently “standard, usual, typical or expected” in the UK as per the dictionary definition of the word.

One doula observed “Normal is the wrong word to use because right now a positive physiological vaginal birth is NOT the norm”. So is there any value in naming it as such when by a simple dictionary definition that could not be further from the truth? I think there might be, but more of that later.

BirthChoiceUK addresses the issue on their website (read the full page here) and explain that “The term normal birth is not meant to be judgmental in any way. We are instead trying to produce some measure of how much technological intervention is currently used in birth. These statistics of course do not tell us anything about a woman’s experience of birth which is likely to be of far more importance to her than whether she was induced or had an epidural or had her waters broken. It is hoped that every woman can have a fulfilling and positive experience of birth regardless of the interventions she has received. This is, of course, much harder to measure!”

And where does birth trauma come into all of this? What of the women who have had negative experiences of birth? What can the word “normal” possibly mean to them? And for those women who have had a “normal” birth as defined by the NCT and AIMS, are they still entitled to feel traumatised if their experience was not a positive one? It was discussed at length that so many apparent problems with the language come from individuals conflating the words “normal” and “positive” but throughout society we find people and cultures who believe that the two are one and the same thing. “Normal” is a generally positive term, meaning good things, which is of course a whole discussion in itself. Nevertheless it is easy to see how a woman with a negative birth experience will not thank you for telling her the birth was “normal”, and how a woman who has had a positive experience will be unhappy with the idea that hers was not a “normal” birth.

So apart from the need to gather statistics across maternity units, what other uses does this idea of “normal birth” have? Midwife Jenny Hall was kind enough to explain “The need to differentiate what is ‘normal’ and not does come down to the legal responsibilities of a midwife. A midwife is in law able to care for women without other health professionals until the process moves into areas outside the boundary of ‘normal ‘. She then legally has to refer to someone else for assistance.” There is then an important legal issue here, and other birth professionals on the group emphasised that for them the term held no value judgement at all:

“I think of normal birth as a spontaneous vaginal birth with no intervention at all, but I’m a midwife and we use these terms as classifications rather than attributing any value to them…… When I talk about normal I’m not using it in a judgemental way, just descriptive, but I am mindful that many find this term difficult.”

Yet throughout today I have had the creeping suspicion that two of my viewpoints don’t match up. I was questioning the use of the word “normal” for a maternity experience that is how human females have been designed to birth their children, yet I am constantly banging on about the need to “normalise” breastfeeding. An uncomfortable feeling of double standards was edging up on me. Giving the whole subject a bit more thought, I commented:

This angle is well articulated by Professor Soo Downe in her interview with midwife Sheena Byrom:

Miranda Dodwell of BirthChoiceUK was keen to emphasis the historical perspective: “having been working on the ‘normal birth’ agenda since about 2003, I realise how far we have come to be having this debate.” She recommended further reading in the shape of Practising childbirth activism: a politics of evidence “about the importance of introducing the concept of normal birth in terms of childbirth activism in driving change.” However, she and others were happy to discuss the idea that it may now be time to move on from the concept of “normal birth”, despite “the power it has had in creating a change of perspective towards women’s experience of maternity care“.

If we are to move on from this terminology, what are the alternatives? Both in terms of new words and in terms of new approaches? There were a number of suggestions from birth professionals:

“Unassisted birth would probably be closer to the mark but the meaning is associated with ‘free birthing’ these days. l guess for me ‘normal’ could be what the woman was expecting and not our version of normal.”

“When I hear the ‘normal’ discussion and how heated it gets I don’t have a satisfactory alternative to the word ‘normal’. Physiological?…bit of a mouthful and a challenge to spell. Vaginal? Many struggle to include the word vagina in general conversation so possibly unacceptable?”

“Rather than focussing on ‘normal’ l tend to look at how satisfied the woman is with the outcome. It’s her birth so she should define it.”

“I tend to use words like ‘physiological’ and ‘needed help’ or ‘complicated by’. Rather than normal, which has different connotations.”

“From the point of view of mums talking to each other about their births… I’d say ‘normal’ is too vague, fairly meaningless, and not generally used. ‘Natural’ is used a lot.”

“‘Physiological’ may be technically correct, but sounds so much more excluding than a two syllable simple Anglo-Saxon word. ‘Natural’ also has a lot of judgemental baggage.”

“Personally, I think maybe the accessibility of the term normal is what’s become problematic about it? ‘Physiological’ seems more medical, so perhaps using this term would prevent women feeling judged?”

But as you can see consensus was hard to come by. Amy Prodgers (@BirthSalford) summarised, I suspect, the feelings of many in the discussion:

As a possible, and remarkably simple, solution, one of the group’s midwives suggested “Why not use the term birth? And let the categories be an additional ‘box to tick’ not together with ‘birth’ am I making any sense??? So ‘birth of baby boy’ (male infant etc etc) then tick, vaginal/forceps/water-pool/home/hospital and so on and so on) – the word birth describes the event – that’s exactly what took place #languagematters. It’s just habit in maternity services, it could easily change – the hospitals/birth centres/ organisations etc could still get the much needed figures”.

Southwark Belle furthered this thought “I think we’re now at a stage where defining one set of choices/circumstances as ‘normal’ / best and using that to set targets just risks swapping one dogma for another. I much prefer treating it all as birth and each intervention individually rather than lumping a whole lot of things in together.”

So is birth just birth? Each instance its own unique set of circumstances and experiences? Can hospital notes and databases possibly be built with this in mind? Can statistics be gathered on this basis? Does the biological, historical way of giving birth need to be normalised to the benefit of families or are all modern options equally valid and ‘normal’?

This comment stands out for me, from Seana McCoy Talbot (an NCT volunteer who is standing for election as NCT President):

“Our starting point always has to be compassion and empathy, but also to know the evidence. It’s instincts plus knowledge. Heart and head. Art and science.”

A while ago we decided to pick six words that we felt really summarised Matexp. As with the healthcare six C’s, we very much wanted our values to reflect what we feel is important to a good maternity experience both for families and staff. So with this in mind, the six values we chose were;

Choice

Kindness

Language

Respect

Dignity

Compassion

We set about asking everyone on facebook and twitter what each of the values meant to them.

Choice

Our first word was choice and we knew when it comes to maternity experiences is so important to families. So what did everyone say about choice?

“Choice to me means having the same services and facilities available to all women. Birth experiences shouldn’t be a postcode lottery.”

“Choice to me means being presented with the correct information so you can make an informed decision. An informed decision is an empowered one.”

“Choice means to me, that all women whether low risk or high risk have access to the same facilities & are given the opportunity to make an informed decision to choose how & where they birth without judgement or pressure even if it is not medically advised.”

“Choice to me means that we give families accurate, unbiased info so they can make a informed choice that is right for them. Then support them in that choice.

“Listen, really listen to women and let them pour out their heart and get to know what they need to make their birth what is right for them.”

“Choice is about being given all the information you need to make a decision in an unbiased, non-pressurised way.”

“Choice is being told the benefits and risks associated with each option. Choice is being told the benefits and risks with your alternative options (it’s very rare that there is no alternative option). Choice is being told what happens if you simply do nothing. Choice is knowing how decisions made now will effect your future, I.e.surgery can have implications on future pregnancies. Choice is being able to consider all the information in relation to your own individual situation/ beliefs/ personal history, allowing time for you to make a rational decision. Choice is having balanced open informative discussions feeling that your decisions are supported and not judged. There is no ‘we are just going to’ or ‘we will’, choice is the individual making the decisions.”

We were reminded of nice guidelines for discussing risks and benefits and also CHOICE top tips for maternity care providers.

Another really interesting point was raised about choice,

“In some circumstances there are no choices, and support needs to be given to those mothers who have had their choices limited or removed.”

Sometimes we may have no choice, in that due to circumstances beyond our control we may have to give birth or accept a situation that is far from the choice we would have made or choices have to be made for the wellbeing of mother and/or baby.

“Following my daughter’s death I have questioned the decisions we made many times wondering if a different choice may have meant she’d lived. In my subsequent pregnancies the feeling of responsibility to make the right choice has at times overwhelmed me and made me very anxious. In lots of ways I’d have preferred to have just been told what was going to happen.”

It was also raised that choice means accepting the consequences of the choices we make, both as staff and as families. Sometimes this can mean impossible questions that may never be answered.

“Sometimes we are given the illusion of choice. How information is presented is so important. Manipulated or coerced compliance can be made to look like choice. Yet, within maternity services, it’s hard to challenge this. Some caregivers reveal their own opinions in how they phrase information – about whether induction, or cs, or epidurals have risks, for example. This sometimes is presented differently to data about home birth, or vbac, or physiological third stage.”

What did become clear was choice must be Clear, unbiased, informed and not an ‘illusion’. That families didn’t want those responsible for their care to manipulate information or data to coerce a choice that they felt was right. Instead information given should allow for families to make choices that were right for them.

Yes when it came to choice, it was evident how important this was to a good maternity experience.

Kindness

Next we chose kindness. While many things matter during birth, simple acts of kindness can leave lasting impressions and mean so much.

“True kindness is something you give without expectation of any kind of return, not even a thank you. It’s instinctive and comes from the heart and will always benefit another heart. You don’t have to touch, smell, see or hear it but it can awaken your senses and light up your soul. It’s something that both the giver and receiver benefit from.”

“Kindness to me also includes understanding- even if you don’t make sense or or thoughts are irrational. It’s such a confusing time, someone being kind and saying ‘it’s ok I understand’ means the world.”

“Kindness is SO important. I have met many kind midwives and each time a small gesture has been performed it has meant so much. I will never forget the midwife who made me a cup of tea in the small hours after Luka was born. I was literally (emotionally and physically) broken and her kindness fixed me up enough to carry on.”

“In order to be truly kind one needs the time to be kind. How many people are in such a hurry during their day, under too much pressure or thinking of the next job, to afford true kindness? Kindness means kind words but it also means listening, accepting & acting on the kind thoughts. If you see a person in distress, true kindness is actively easing that distress both verbally and practically.”

“Kindness should be in everything we do. We should treat all women with kindness because it’s the small things that matter too. Even the most difficult, hard and situation can be made a little easier when we are shown kindness. People remember kindness and if we truly seek to show kindness it will affect how we care for women. I believe it should be one of our inner values that we keep and not allow the culture to eat away. It costs nothing and yet can have the biggest effects.”

“Kindness is being empathetic and showing the person that you understand how the person is feeling and showing that you care and that you understand.”

“A quick Google search says “Kindness: the quality of being friendly, generous and considerate.” Generous is an important one. To be kind, in my opinion, means to give of yourself, to do something that takes a bit of extra effort. To deliver a home cooked meal to a family with a new baby is kind. To offer to take baby for a buggy walk whilst mum has a nap is kind. To make a busy parent a cup of tea is kind. To be generous with your time and your abilities is kind. As for “considerate”, this is the one where language is important. Consider what language you are using and the impact that can have on a person. Speak with kindness, aim to boost a family’s confidence and pride rather than to leave them confused or with feelings of inadequacy. Consider how you would wish to be treated in the same situation. Consider what you know of the family and the impact those things might have on their experience.”

So kindness was a valued part of maternity care and many expressed that kindness had made a real difference to them, however small the act.

It was also raised that it is important to also show kindness to those who care for women.

“As families we must not forget that there are times for us to be kind. To be friendly or at least polite. To drop off a box of chocolates on the ward to say thank you. To donate some items to the hospital. To raise money for units that have cared for our children. If we have been fortunate enough to receive kindness we should remember to pass it back or pass it on.”

Yes Kindness in words and deeds really does make for a good Maternity experience for all.

Language

Language is something that is discussed a lot in Matexp, and something that is very important to so many. Language has the power to build up, encourage and empower or to tear down, increase doubts and intensify fear. The words we use can leave lasting impressions.

“Language sets the tone for every experience. What is said, translates into what we hear and that affects how we feel. Being told I was 2-3cm and could go home if I wanted to it was ok. But what I heard was, I’m a failure, I’m not progressing, I’m wasting everyone’s time. It didn’t matter what was said to alleviate those worries, they were now engrained. Also, the word normal is a horrible word and should be replaced with various other descriptive words that can resonate more with the mother. Language is communication, understanding and respect.”

“Language is about reducing the distance between provider and parents and creating a collaborative ‘us’ rather than ‘them’. It’s as much about listening as talking, and it’s about choosing words that come from kindness, even if we can’t avoid the risk that they’re not always received that way.”

“It’s not just the words themselves (although these are important!) but also how it’s delivered. Positive phrasing is important we need to ban certain phrases IMO! A big cultural shift around certain stock phrases is needed. It’s about having a two-sided conversation/discussion in relation to decision making ultimately with the individual involved making the decision with all the facts available, I.e. looking directly at a person when talking, hello my name is campaign, doing admin once individual left room rather than spending lots of time looking at screen or doing paperwork etc.”

“For me language and the way we use language can convey so much. It should always be used in a kind way mindful of the person and their situation. Listening is so important as is thinking about the words we use. Our language should convey that we care, are interested, want the best for that person and that we are genuine. It shouldn’t be harsh or critical or brash.”

“If you can’t say anything nice, don’t say anything at all. Don’t fill silence with platitudes. Judgement is implied in so many statements unwittingly uttered when they fall on the ears of person who is suffering / has suffered a trauma. Instead hold a hand, mop a brow, smile, rub a shoulder but be so careful. It’s easy to say “well you are mum now you’ll put your baby first…” wh
en a new mum admits she feels awful, it’s said without malice, as a statement of fact as you see it BUT to the traumatised mummy it can say something different. To me it said “selfish mum, thinking about yourself, crap mum can’t do it” and so I hid how bad I felt and went home with retained placenta and developed sepsis. Think before you speak.”

Words without: Attitude Contempt Judgement or jargon Chat ‘with you’ not ‘to you or above you’ Words should not be dismissive or exclusive Words of kindness always…Words are but leaves, deeds are the fruit.”

“The words we use provide the framework for our thinking. I can tell by the words you use what you think and therefore feel about me. Language is about communicating. We need to develop and agree a shared language to do this well. I don’t really care what your “correct terminology” is unless we have established what it means to us in this relationship. If you are not sure what words to use let’s talk about it. It’s a great way of building trust.”

“Language for me is one aspect of communication and facilitation and if we use it with the aim to facilitate then we are on the right track- this means personalising for atmosphere, experience, individual on a moment by moment level. And we must match the language with all other aspects of communication otherwise it is hard for women to trust in us as the words we use seem at odds with body language etc. Language should be used to empower, inform, educate, provide choice in a non judgemental safe, exploratory non defensive manner. That is the ideal. Consent, not coerce, create chances for inclusion in the care relation ship and take care in the words we choose- as said above we all take things in different ways, but if we are authentic in what we say then that’s a good start.”

Two words in particular that came out as needing to be thrown into room 101 and these were;

“Failure“ and “incompetent”

Language is a very important Heart Value. We need to think about the words we use, but also the way those words are used. Language can greatly affect birth because words are so powerful.

Respect

We would think that respect would be an obvious part of a maternity experience, but sadly many women and staff say they feel it is lacking.

“To me respect means an absence of any type of prejudice. It means getting to know the individual, not treating everyone the same. Acknowledging the family’s history, experience and their knowledge and understanding without making assumptions. Respecting the mother’s decisions as much as her body.”

“Respect is valuing people and listening to/valuing their opinions even if they differ from yours. Finding a way to use these collaboratively when making plans. This respect should go both ways too, no point looking for respect if you’re not giving it.”

R … RespectE … Every one’sS… Sensitive soulP… We are just peopleE…Eager to do our bestC… Careful how you say thingsT … Two way communication needs kindness & respect.

“Due regard to the feelings or rights of others is where respect really hits in #MatExp. We must give due regard to the feelings and rights of families, whatever our personal views or experiences.”

“Avoid harm or interfering with” – another crucial one. Sometimes these feel mutually exclusive in some areas of #MatExp – can we avoid interfering with mothers and babies but still avoid harm? If in doubt, we go back to respecting the feelings or rights of others. And of course we have to consider whether the baby has rights as well.”

“Respect is valuing the person’s point of view and valuing them as a person. What they want, what they feel and this should be discussed with the woman. Actually to define respect is not that easy. I was thinking how the medical profession has commanded respect and still does and it is very aligned to value.’

“Based on my personal experience, respect is knowing and understanding that this is MY body, MY pregnancy and MY baby NOT yours (health practitioners); hence LISTEN to me, give me OBJECTIVE information to help me to make ‘INFORMED’ decisions and FIGHT/ADVOCATE for my wishes. Don’t give me your opinion if I haven’t asked for it and recognise my birth doesn’t fit round your schedule but the other way. And everything everyone has said so far.”

Respect also encompasses staff and the environment they work and care for women in.

“The first part is the respect I hope all birth professionals command, as they are doing an amazing job.”

“Agree to recognise and abide by”. Do all of the guidelines and protocols in your hospital or birthing centre command respect? Do you respect family’s birth plans? Do families respect your recommendations? Can all of these things be married together? Respect encompasses a huge amount of concepts. We all want it and we’re often slow to give it.”

“It also means respecting each other as staff, working as a team and supporting each other’s roles. Respect also included speaking up when we see wrong attitudes or treatment. It also means the respecting of other view points and realising we can all have different perspectives and that’s ok.”

Respect for women, their families, beliefs, choices and needs MATTERS. Staff too need respect for each other and but also afford respect for the amazing job they are doing.

Dignity

How can we respect a woman’s dignity in birth?

“For me dignity means, allowing me to make decisions without health professional over riding them and making you feel as though you’ve said something wrong.”

“For me respect and dignity come hand in hand. Whatever happens if you have treated me with respect I will be able to preserve my dignity. Labour and birth put you on a very vulnerable place and being respected means whatever procedure or conversation takes place involving very intimate issues, I will feel like I am a human being rather than a problem or hinderance, or worse still, like there is something wrong with me, which is my fault, not a result of the circumstances.”

“Dignity is treating me in a way that doesn’t make me feel I’ve outstayed my welcome on the maternity ward.”

“For me, dignity is about human rights, and human rights are about being treated with respect…a pregnant woman or a woman in labour is entitled to her human rights being respected at all times, and she is entitled to be treated with dignity…there!”

“Recognise that respecting privacy, DIGNITY and autonomy is not an addition to care provision, but an integral part of good care…”

“Being spoken to as a competent adult rather than a naughty child, people introducing themselves before touching me, people remembering I am a person not just a uterus on legs.”

In fact this summed Dignity up perfectly.

Compassion

Last of our Heart Values, but by no means least, is Compassion. Some would argue that compassion alone is the single most important thing we can shown women in a maternity experience, if all care is based on compassion then it will encompass all the other Heart Values.

“To me compassion is seeing a person, realising that they are in need of not just your medical care but your emotional support, kindness and often just to know you actually care. It involves thought, as it can be such little things that make a difference. Think, if this was my daughter or sister how would I want them to be cared for ?”

“Compassion to me is always about time, the extra couple of seconds to smile at someone who looks worried; the couple of minutes to listen to someone who has a question or to ask someone who looks lost on a corridor if they need help; right up to the tasks that take a lot of time.”

Do we see compassion in maternity?

“When I was very sick waiting to have Joseph no one had any time to just sit with me, so the staff got a student midwife to sit and hold my hand. I’ll never forget her kindness. So even if there is no time sometimes there is another way.”

“I was really surprised when I was critically ill. I had a midwife refusing to leave as I was so poorly, she made sure she was my midwife 3 nights in a row. I had so many hugs from so many doctors, midwives, health care assistants I can’t count. I had my 27 weeker in an LNU rather than a Level 3 and they pulled out all stops so we could be cared for close to home.”

“One of my favourite consultants wasn’t even one of mine. Every day he would see me going to Joseph (over ten weeks) and give me a hug and tell me what a lovely mum I was. He was a huge support to me and probably had no idea.”

“For me, it was when one of my consultants told me “your baby *will* be premature”. I started to cry and she put her hand on my arm. It was such a human touch and I was so grateful. But I’m guessing that’s generally not encouraged, whereas for me, it meant so much: it said, I understand and I know this is hard. For me as well, it was when I finally left the hospital and one of my midwives gave me a big hug.”

“It was the array of midwives who looked after me for 10 days talking to me and making me feel almost as if I was just in a second home (ha I was in for 2 weeks which felt like a long time).”

“It was all the consultants who I had come across, always stopping when they saw me to ask how I was and how baby was doing. It was consultants who came to find me the next day to see how I was doing post c sec.I didn’t really expect that, as they must all be very busy people, but they never gave that impression of being in a rush etc.”

“I had so much kindness and compassion when I was in hospital with Joseph, my favourite was the day after Joseph was born, he was ventilated in NICU and I was in my room. I knew I couldn’t see him that day, and had been warned it would be Monday, this was Friday. I quietly crying and the obstetrician reg Charlie came in and said “why are you crying” and I said “I’m fine, I’m hormonal and still very ill and just feeling a bit sorry for myself”. He said “Nonsense, you need to see your baby and I WILL make it happen”. He spent hours organising everything to get me to NICU to see my baby, I will never forget his kindness and him realising that was what I needed, and being prepared to make it happen.”

Can we as families show compassion to staff?

“For staff I believe we should remember the hard work they do and commend them for that. Also be respectful to them. Also compassionate towards each other as a team. Help each other, treat with respect, and value each other’s gifts and abilities. Compassion I truly believe goes a long way when it comes to improving Matexp for all!”

“Immediate thought: always offer your midwife or health visitor a brew when they come to your home, coz they work bloody hard smile emoticon And we know that in the UK tea = compassion.”

“Give thanks and praise where it’s due, people are so quick to complain but never to give thanks. For HCPs, spend 1 moment before each meeting to take a deep breath, rid yourself of other thoughts and allow all focus to be on the couple/Mama you are going to speak with/assist.”

“One of the biggest revelations I’ve had this year, during a fairly turbulent time, is that it is impossible to practice compassion as a HCP towards women day in day out unless you also practice self-compassion.”

“This thread has inspired me. Tonight the children and I are going to bake a big chocolate cake and then tomorrow deliver it to the Labour Ward as a thank you to all the exceptional midwives who work so hard there.”

So those are our six Heart Values. These values are the heart of Matexp, they permeate the actions we make to improve maternity services everywhere.The Values will continue to grow and expand as Matexp does too.

Thank you to everyone who shared their thoughts and ideas with us. We had so many it was impossible to include every single one here, but we hope all the above comments capture the thoughts of women, families and staff.

Matexp is amazing and will make changes for families everywhere. A woman will remember her birth for the rest of her life so lets make sure we do all we can to make her maternity experience one she remembers for all the right reasons, which we can if we remember our Matexp Heart Values. Lets but the heart into Matexp.

#MatExp has seen more interaction on social media than ones about similar issues (not that it’s a competition, but what is so brilliant about #MatExp is that there is no limit to the number or type of people who can get involved because it’s by everyone, for everyone).

This next stat is VERY exciting:

Since #MatExp started being used as a hashtag there have been – drumroll please…

Yes you read that right – more than 152 million!

(Impressions means that Tweets bearing the #MatExp hashtag would have been seen on that number of timelines)

Guys and St Thomas’ Hospital held a Whose Shoes workshop, and seems to have inspired everyone who went, with 100% of attendees saying it would impact on their practise!

Being the language champion, I’ve been heartened to see so much chat about the issue with people from all sorts of professions and specialties taking on board the importance, value and impact of language.

I was delighted to find this paragraph below on a site called lulubaby, which offers a range of courses to ‘prepare you for life with your baby’.

Words of common sense – “…you cannot sadly guarantee yourself a ‘natural birth’, even with the greatest willpower and determination…” fill my heart with joy. No mention of ‘low risk’ or ‘high risk’ either – let’s hope such common sense becomes much more common!

Next week, I’m attending the listening event, the first of the National Maternity Review team’s activities. I’m going to be there as part of #HugosLegacy as well as #MatExp – I’ll be sharing my own experiences as well as thinking about how #MatExp can connect with the National Maternity Review team to make things happen. Flo and Gill are coming too – we spend so much time connecting on social media, it’s great to be able to catch up face-to-face sometimes too.

So! We’ve been rather busy. Which is why we have been seeking ways to create more hours in the day, such as getting a job lot of time-turners, like Harry Potter’s Hermione.

And we’re going to need them, because after the summer we have LOADS of exciting things going on, such as NHS Expo, and a #MatExp conference – watch this space! I’m looking forward to meeting even more of the #MatExp community, many of whom have become friends at these events.

All of the #MatExp community are busy doing something positive every day, of course. A huge THANK YOU to you all. These are for you for taking the time to get involved, share your stories and to make a difference to women, babies and their families. Forget-me-nots are very special flowers!

There is so much going on – Helen, Emma, and Susanne are also capturing as much as they can in their fab posts; it’s impossible to capture everything, but please know that every action and activity, whether big or small is greatly appreciated.